The Caring Encounter Between Patient and Nurse Within a Mental Health and Psychiatric Care Context

Nursing and Palliative Care

Research Article ISSN: 2397-9623

The caring encounter between patient and nurse within a mental health and psychiatric care context – as described by nurses working in an emergency polyclinic Hemberg Jessica1* and Lipponen Sofie2* 1PhD, RN, Department of Caring Sciences, Åbo Akademi University, Vaasa, Finland 2MSc, RN (Psychiatric Nurse), City of Helsinki, Finland

Abstract Aims: This study aims to explore, from a caring science perspective, what constitutes and creates a caring encounter between the patient and the nurse within a mental health and psychiatric care context. Methods: The study uses a hermeneutical approach. The material consists of interviews with nurses working in an emergency polyclinic regarding their understanding of the encounter between a nurse and a patient. The texts were interpreted through hermeneutical reading. Results: This study shows that love and communion are the basis for the caring encounter between the patient and the nurse. Recognition of the patient is essential. The patients’ first impression is decisive for the caring encounter. The personality of the nurse is the key for establishing trust in communion. The uniqueness of the encounter demands openness in the nurse. The room is the basis for the encounter and for safeguarding the patient’s integrity and vulnerability. Vulnerability is thus in this study seen as the guiding-star in the caring encounter between the patient and the nurse within a mental health care context. Conclusion: Vulnerability as a phenomenon plays a fundamental role in the caring encounter between the patient and the nurse in a mental health and psychiatric care context. Future research should further explore this area regarding vulnerability within a mental health and psychiatric care context, but also in relation to different care contexts.

Introduction turn can lead to suffering and anxiety. In addition, people with mental ill-health are reported to be stigmatized [3]. Mental health care in Finland, especially psychiatric emergency care, has undergone great changes from having been free-standing and The 1980s’ experienced great progress within psychiatric care [4]. in 2015 moving to the emergency polyclinics [1]. Concern was raised The international psychiatric diagnostic handbook was published; in public debates about how patients with mental ill-health would be projects for developing health care for patients with schizophrenia treated in this new emergency polyclinic environment and what new were initiated and succeeded in reducing the number of suicides; the challenges this would entail. Other issues that were brought to the fore development of training in psychotherapy began; and new drugs for in connection with this change were: what is a caring encounter with depression appeared on the market [4]. According to the National patients with mental ill-health, what takes place in the encounter and Institute for Health and Welfare in Finland [5], mental health care what are the hurdles and challenges? services refer to such activities that prevent, alleviate and treat psychic disorders and their consequences. Mental health promotion is also Treatment and knowledge of how we approach individuals with included in mental health care. The services include supervision, mental ill-health has greatly improved during the last twenty years, counseling, and, depending on the patient’s need for psychosocial but there is still room for development. Even a fleeting or short support in situations of crisis and examination, treatment and encounter may be significant for patients and pave the way for trust rehabilitation of individuals suffering from psychic disorders. and communion [2]. This qualitative study aims to examine the caring communion between patients and nurses within a mental health caring Deficiencies in encounters with patients are common. The nurse context. needs to be aware of patients’ vulnerability in their life situations and Background Correspondence to: Hemberg, Jessica, PhD, RN, Postdoctoral Researcher, Mental ill-health is a great concern in society and within public University Lecturer, Åbo Akademi University, Faculty of Education and Welfare health in the Nordic countries today. Mental ill-health is a concept that studies, Department of Caring Sciences, P.B. 31165101 Vaasa, Finland. E-mail: is used for different mental disorders. These include for example mental [email protected] illnesses, depression, different panic and anxiety disorders, abnormal Lipponen, Sofie, MSc, RN (Psychiatric Nurse), City of Helsinki, Finland. E-mail: psychic reactions, sleeping difficulties, eating disorders, sexual [email protected] disorders, behavioural and personality disorders as well as addictions. The human being who suffers from mental ill-health experiences a Key words: nurse, mental health, psychiatric care, psychiatric emergency decrease in the ability for action, quality of life deteriorates, which in Received: March 14, 2017; Accepted: April 03, 2017; Published: April 06, 2017

Nurs Palliat Care, 2017 doi: 10.15761/NPC.1000147 Volume 2(2): 1-7 Hemberg J (2017) The caring encounter between patient and nurse within a mental health and psychiatric care context – as described by nurses working in an emergency polyclinic

take this into account in the care. A meaningful encounter can awaken the encounter is crucial for the patient [7-9,12-13,18] because it may feelings in both patients and nurses [6]. A true caring encounter has affect the quality of life [10]. Therefore, this study sees it as relevant and the potential for communion between nurses and patients [7-9]. The meaningful to further explore this area. characteristics that express communion include sharing, listening, Aims instilling hope, responsiveness, touching, affirming, encouragement, showing empathy, giving advice, providing comfort and support [10]. This study aims to explore, from a caring science perspective, what constitutes and creates a caring encounter between the patient and the A caring encounter presupposes an invitation of the patient by the nurse within a mental health and psychiatric care context. nurse through openness where the nurse builds a bridge between him- or herself to the patient [11]. The encounter can be seen as an invitation Theoretical framework to communion where the nurse encounters patients in a way that makes Caritative theory is part of the caring science tradition [20,21]. them feel welcome and invited to participate in a caring communion According to the ontological perspective of caring science, health is [12,13]. By being present, the nurse invites the patient to the encounter understood as a “becoming”, which implies a movement towards a [7]. The encounter can take place through a conversation with the deeper wholeness and holiness. A movement occurs, when the human patient or simply through being present in the moment. Patients being’s inner health potential is touched and this may be seen in the often feel that they do not receive enough time for discussing with different dimensions of health. The dimension “doing” implies what the nurses [14]. A caring act can only be caring if the encounter between human being does for his or her health, “being” means the endeavour nurse and patient is characterized by positive interactions, intentions to achieve balance and harmony, and “becoming” pertains to a deeper and attitudes [10] Thus, the caring act can be caring, for instance, level of integration and feeling of wholeness [20-22]. when the nurse is actively engaged in the patients’ lives through understanding and true presence in conversation and shows interest According to Eriksson [23], caring is understood as a natural in their experiences. Patients experience communion when they can human behaviour which implies cleansing and nourishing, and share their burdens with the nurse. Trust is crucial in the encounter spontaneous and unconditional love. All human beings are believed [15]. The encounter reflects a nurse’s attitudes and approach toward to be natural caregivers and natural basic caring is expressed through patients with mental ill-health and whether the nurse is able to create a tending, playing and learning in a spirit of love, faith and hope. The sense of trust in patients [14]. An important factor contributing to the characteristics of tending are warmth, closeness, respect, honesty patients being able to open up and feel trust in the encounter was the and touch; playing is an expression of exercise, testing, creativity and environment in which the encounter took place. In addition, Björkdahl imagination, and desires. Learning implies sharing. Caring attains its [11] indicates that the environment and the nurse’s education are distinctive character through the caring communion [24]. A caring important aspects that affect the encounter. The nurse is responsible communion cannot be taken for granted but presupposes a conscious for creating an encounter with patients that is characterized by trust effort to be with the other. By being involved in the suffering of the and openness, but nurses should also act as “guardians” and make sure patient, by being a co-actor in the drama of suffering, as it were, the the care is safe. The encounter develops through warmth and trust. nurse can support the patient and thereby create a caring communion The first invitation to an encounter is often non-verbal and in the encounter [25]. The act of caring contains particular caring represents a platform for the creation of an encounter. The nurse should elements that invite deep communion. The human being longs to be not view the patient as a passive participant in the encounter, but as loved and to love and can find this through communion [25]. In the someone who can influence its content [11]. In the first encounter, encounter, nurses emerge from their own world and offer themselves the nurse encourages interaction with the patient. This is similar to to patients. The encounter demands of nurses genuine concern for and research by Johansson, Skärsäter and Danielsson [16] who indicate attention to patients because when love becomes evident the human that the encounter is the fundamental category in the art of caring. being can heal. This form of caring love that exists in a caring relation This art can be seen as nurses’ potential to use their own creativity can be explained as a sense of connection and the nurse’s willingness to to create a meaningful contact with patients [17]. This meaningful be there for patients and help them [26]. The caring communion is seen caring encounter may include understanding, open conversation, as the source of strength and meaning in caring [21]. insight, strength and solutions. At best, the encounter is an expression of solidarity and closeness where patients can come into contact with Methodological aspects themselves owing to that the nurse receives them with openness, offers The study is inspired by a hermeneutical approach according to support and is flexible. Nurses’ affirmation of their own vulnerability Gadamer [27]. The material consists of interviews with nurses working is a condition for the possibility of entering the encounter with the in an emergency polyclinic regarding their experiences of interacting patient to create trust [18]. The communion between the nurse and the with patients in mental ill-health in order to create a caring encounter. patient in the encounter is characterized by their meeting each other The texts were interpreted through hermeneutical reading [28]. on the same level [8]. Both are active in the encounter and the nurse shows understanding and instills hope in the patient. The longer the Data material, data collection and ethical considerations caring relation lasts the more the patient can see the signs that the nurse genuinely cares about and knows the patient. Patients experience they The data material consists of interviews with nurses working in an have good contact with the nurses when they work together for the emergency polyclinic and their experiences of interacting with patients fulfillment of the same goal set up by the patient [8]. The patient desires with mental ill-health and creating a caring encounter with these. to be seen and understood; therefore, it is important that the nurse The interview data was gathered in five face-to-face interviews, with is present in the encounter [9]. Not only does the encounter make a total of five participants (three females and two males). The age of patients aware of their suffering but also enables reconciliation [9,19]. the participants varied between 25 and 50. All of the participants came from a similar urban background and had a similar socioeconomic As earlier research suggests, the caring communion and trust in as well as ethnic background. The inclusion criteria were that all

Nurs Palliat Care, 2017 doi: 10.15761/NPC.1000147 Volume 2(2): 2-7 Hemberg J (2017) The caring encounter between patient and nurse within a mental health and psychiatric care context – as described by nurses working in an emergency polyclinic

participants should work as nurses or mental health care nurses at that the patients do not feel overlooked. The patient has in the good an emergency polyclinic and that they should have worked within caring encounter been treated and helped in a way that leaves a positive mental health care a few years. Another inclusion criterion was that and respectful echo, even if the nurse had been forced to limit the the participants should be specifically trained for working within patient’s wishes and subject the patient to restraint. The nurse has then mental health care. Three of the participants had worked the majority shown that the patients’ wishes have been heard and understood but of their active years at a psychiatric emergency. Two participants had the nurse has still carefully motivated why he or she cannot give them long experience of psychiatric non-institutional care or treatment of what they want. It is important that also next-of-kin are being heard out-patients as well as of institutional care or treatment of in-patients. and allowed to express their thoughts and concern about the situation. One of the researchers contacted a large emergency polyclinic within the city of Helsinki where the participants were recruited. Those who The interplay is successful when the effect on patients is that they accepted the invitation received oral detailed information about the feel they have had a good experience of the encounter and the treatment study and were given brief information about the main topic of the and that they have been heard and perhaps in some way understood, interview. The participants were informed both orally and in writing and that they have received an answer or some kind of help for their about the study purpose, confidentiality and withdrawal of consent. problems. One should not expect that the emergency polyclinic patients Each interview lasted for about 30-60 minutes, and all the interviews should be fully satisfied because we must sometimes disappoint them were digitally taped and transcribed. Permission to conduct the study when we cannot fulfill all their wishes, but the interplay is successful was granted by the ethical committee at the head organization were the when patients leave with a sense that someone has understood his or data was conducted. The study follows The Finnish National Advisory her problems. A good encounter is hence about the patient’s experience Board on Research Ethics [29]. after the encounter. (Interview person d) Hermeneutical reading of texts It is important that nurses are responsive to what the patient says and do not draw conclusions based on their own prejudices or The aim in hermeneutical reading [30] is to uncover the inner preconceived ideas. In addition, it is important that the nurse remains essence of the substance that rises up in the text in order to open up in the encounter to listen and see the patient despite lack of time. It is for a deeper understanding. The readers’ ethical approach to the text also important that patients feel they have the space and permission to is the basis of hermeneutical reading, which assumes that the reader show very difficult thoughts and feelings. Being listened to and having sees texts as an opportunity for new understanding and that the reader someone else see one’s suffering is crucial. is prepared to challenge his or her pre-understanding. Openness and It is not easy but one should strive to listen to what patients are creativity is required from the reader to reveal meanings in the depths actually saying, and not listen to what I think they are saying. Therefore, of the text [28]. one has to pause in the moment and see the patient. Of course, this is The texts from the interviews were read several times with difficult when there is no time to lose, but one should still stop, take it openness in order to find (underlying) themes that led to new questions step by step, because the needs of the patient can be something entirely that were asked to the texts so that the substance in these could be different than what I had in mind. (Interview person c) uncovered. The whole of the text was reflected against the parts and Long waiting hours can prove difficult because patients can feel meaningful units were created from the features that emerged from that their needs and distress are not taken seriously. Patients can then the texts. A continuously moving process between understanding become frustrated, worried or aggressive. When the nurse finally has and interpretation, between the parts and the whole, was obtained in time to encounter the patient the patient may already be upset. order to uncover the substance beyond the present. Finally, the reading resulted in five main themes. The patients’ first impression as decisive for the caring Results encounter First impressions are meaningful and decisive because they set The hermeneutical reading resulted in five main themes: the tone for the encounter. This tone or experience later acts as a Recognition of the patient through love and compassion as essential for foundation that influences subsequent encounters and conversations the caring encounter, The patients’ first impression as decisive for the between patient and nurse. It is important to know that the encounter caring encounter, The personality of the nurse as the key for establishing takes place directly and the patient quickly has an idea of the care and trust in communion, The uniqueness of the encounter as a demand for the nurses. openness and The room as a basis for the encounter and for safeguarding the patient’s integrity and vulnerability. These main themes are further The encounter begins immediately as the patient enters the described in the following. entrance hall where a nurse is present and introduces him or herself, tells the patient where we are and what will happen next. If the patient Recognition of the patient through love and compassion as is asked to wait we examine whether the patient’s health is such that it essential for the caring encounter is at all possible for the patient to wait, and, if required, we try to find a A caring encounter can be created when patients feel they are calmer place where he or she can wait… (Interview person b) heard and understood. Nurses then show a genuine willingness to help Patients need information so that they feel important, seen and through love and compassion, even though the situation sometimes cared for. Nurses should always greet patients when they arrive at the requires that the nurse must use restraint or not give patients what emergency polyclinic. They should also inform patients if things are they want. A caring encounter can also be created when the nurse busy in the consulting room and let patients know that they may have helps patients understand what they need so that that they feel that to wait for a while, but that the goal is to have patients see the doctor the nursing staff has heard and understood them even if they do things as soon as possible. against the patients’ will. Then it is important to talk things through so

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The emergency polyclinic is often the first place where patients with know how patients feel and what they need. Thus, openness in the mental problems seek help or are admitted. Coming to the emergency encounter is required as care should be based on patients’ needs. polyclinic can be difficult for patients (if they feel ashamed of their I always ask patients, and ask them to tell me why they have come mental ill-being). Patients may tense up when they seek help and feel here to the emergency polyclinic… this is how the interview begins… alone and like a failure. Therefore, the first encounter at the emergency and then we figure out how we can help. Naturally, there are issues clinic is crucial. Offering a first brief encounter despite lack of time is regarding medication, nourishment and open contact etc. that we ask important. Informing patients make them feel important, seen and feel about, but I always ask the patient what he or she wants and how we can that they have come to the right place. help here at the clinic. (Interview person c) Of course one seeks to always go and say hello to new patients. One Sometimes the encounter must be brief because of the patient’s also has to decide which of the patients to take care of first, even though condition. The nurse cannot and does not want to burden the patient one is busy and it is a hectic working environment, because there may as the patient may be in a very frail condition. In this case a brief be different patients with different needs at the emergency polyclinic. encounter is preferable. The nurse uses short sentences and in this way (Interview person e) creates a sense of safety and trust. Especially patients who are psychotic The personality of the nurse as the key for establishing trust and disoriented can benefit from a brief encounter. The goal should in communion be to attain a caring communion through cooperation. Having to wait may also be therapeutic for these patients, and even if they criticize The personality of the nurse is key and a tool for creating trust in being forced to wait for a long time, it is sometimes precisely this communion in the encounter with the patient. The nurse’s showing form of care that is practiced. Nurses must be attentive to patients and respect and recognizing the dignity of the patient is essential for a not automatically believe they know what the patients need. It is not successful encounter based on trust to take place. Those who work possible to prepare for an encounter in advance. Each encounter is within mental health care, specifically in emergency polyclinics, cannot thus a blank page and one should therefore enter it with openness and hide (for instance, behind technical or care measures because nurses without expectations. The non-verbal communication is important in themselves and their personalities represent tools in the encounter the encounter because it immediately signals whether one is present in with patients). This is because nurses must use their own personality in the encounter or not. their encounter with patients. Each event and encounter is unique. It is important to make time for an encounter, that is, so that one does not The first encounter is important, because it largely dictates how the rush through it and encounters the human being in a careless manner encounter will end. We have had a lot of training regarding non-verbal and make the situation more of an interview than a human encounter. body language and how much communication takes place through facial expressions. (Interview person d) Respect for the patient is emphasized in emergency mental care. Patients come here from different places and with different means of The room as a basis for the encounter and for safeguarding transport, but it crucial that they do not experience that they are being the patient’s integrity and vulnerability belittled or depreciated but that they are treated with dignity regardless The environment and the room create conditions for a caring of circumstances. (Interview person e) encounter with the patient. Calm surroundings, for instance a separate Patients enter the acute situation in emergency mental health care waiting-room, are important in a mental health care context. Patients and their feelings may differ considerably from normal situations. An with mental ill-health are often vulnerable and can, due to the waiting, otherwise calm and rational human being may in a situation of acute be tired or frustrated and then it may be difficult to enter into the crisis behave very differently. Nurses must therefore through their encounter with the nurse. When the encounter can take place in peace behaviour try to calm down the patients they encounter. They should and quiet one can create a trust that becomes the foundation for an show respect for patients and for the reasons they have sought help, encounter. It is not always possible to arrange an optimum room, but and treat them in a human way. Nurses can, through their personality the nurse can, if possible, try to arrange a separate room or a room that and way of being instill hope in patients that things will improve. This is somehow screened off from other patients. In this way, the conditions requires willingness and courage, however. By instilling hope and being are improved for a safe and successful encounter where the patient’s there and sharing the patients’ problems, nurses show their compassion integrity and vulnerability may be safeguarded. The communication should take place on the patient’s terms, that is, the nurse must listen to and concern whereupon trust may emerge. Here the personality of the the patient and by those means respect the patient’s integrity. Honesty, nurse is crucial. By creating trust in the encounter a caring relation for instance, that the nurse does not promise something that cannot in which both nurse and patient feel they have succeeded can then be be fulfilled is crucial in the encounter. The nurse should be objective achieved. and inform the patient about available alternatives. Nurses should If one obtains trust in the care both nurse and patient have a good also explain why they provide the care they do so that the patient does feeling about the encounter, and the patient feels safe to return to this not feel disparaged or ignored. In this way, the patient’s experience of place in another emergency situation. (Interview person a) integrity and vulnerability can be safeguarded. To respect the patient’s integrity the nurse must maintain the patient’s dignity which may have The uniqueness of the encounter as a demand for openness been destroyed because of the suffering. The nurse’s task is therefore to Each encounter with a patient is unique and should be based in the suffering and hopelessness instill a sense of hope in the patient. on what the patient expresses, the patient’s need, not on the nurse’s Consequently, this means that the nurse is willing to share the suffering preconceived ideas. One cannot follow the same pattern with all with the patient and show the patient new prospects and possibilities. patients. The nurse must not exploit the patient in the encounter or Nurses should convey that patients are important to them and will not enter the encounter with preconceived ideas. One cannot in advance be abandoned. Nurses can instill a sense of hope also by considering, inventing and arranging different forms of care so that patients do not

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feel they have sought help at the polyclinic in vain. A caring encounter is fundamentally successful interplay between nurse and patient characterized by a good experience that remains with the The encounter must be matter-of-fact and professional. When a patient as well as with the nurse after the encounter. A good encounter patient arrives, we take him or her to a calm place for a discussion. We is also significant for nurses as they may for themselves assess whether should not do this in the corridor so that someone else may overhear us… It is also important that we reserve sufficient time and one should the encounter has been a good one by observing whether a positive not check one’s watch or in other ways indicate that there is lack of feeling remains from it, even if they discussed other than positive time. The patient should not be made to feel that you as a nurse is matters with the patient in the encounter. pressed for time. (Interview person d) This study has demonstrated that the first impression is decisive The quality of the treatment of the patient is primarily highlighted for the encounter. The encounter begins when the patient enters when the nurse is forced to restrain patients or when their wishes through the door. An emergency polyclinic where patients with are not fulfilled. Then it does not so much matter what one says or mental ill-health come to seek help is often a hectic, restless and does but how it is done. Because patients with mental ill-health often quickly changing workplace. For patients who feel they have been carry a vulnerability that is very fragile their trust can be smashed in a treated well, this experience is highly significant for whether they feel matter of seconds in case the human being’s integrity is violated in the they have received good care or not. If the nurse is in a hurry or gives encounter, and to which the following extract bears witness: patients an experience in which they feel they have been treated in a careless manner in some respects, this has a negative impact on how The patient had finally agreed to care and was willing to get help at they feel they have received care. Patients always compare subsequent the emergency polyclinic… and we went together with the doctor to care to this first impression that has left traces and that can create a see the patient. By the way, the place where we encountered the patient lasting mood in patients that influence their understanding of future was ludicrous, a follow-up room where another patient was present… encounters in a negative way; the encounter does not just take place but the doctor decided that we should talk to the patient there. And with patients but also with their next-of-kin. Patients may have trust this doctor began by grabbing the patient’s hat and took it off from the issues if they have previously sought help but found that they have not patient’s head, whereupon the whole situation came to nothing and the been treated in a dignified way. Then it is even more important that the patient rushed out of there swearing… (Interview person e) nurse approaches the patient extra tactfully so that new hope and trust can be built. Nurses must then be there for patients and show that they Discussion will not abandon them. The results of this study showed that the caring encounter within a This study also shows that the uniqueness of the encounter mental health and psychiatric care context demands patient centering demands openness [11] from nurses. The encounter should be based [8] and recognition of the patient through love and compassion. on what the patient expresses, on the patient’s needs, not on the nurse’s Patients feel that good care has to do with the nurse being there for preconceived ideas. This is similar to research [18] that indicates patients, supporting, seeing and understanding them for what they are that in the communion the nurse should be sensitive to the patient’s [6]. The caring relation requires trust and openness where the nurse experiences and not take the encounter for granted. The present study is constantly present and responsive to the patients’ needs. Responses also demonstrates that one cannot follow the same pattern with all from patients often revel that they do not feel heard or seen for who patients. In other words, one cannot know in advance how the patient they are [6]. Patients who feel ill-treated often blame themselves and feels and what the patient needs. This is why the encounter requires feel that they have not been able to describe their suffering [12]. If openness; something unexpected that happens can prove to be essential patients are not recognized, seen or heard, they may suffer from care in the encounter. [31], which means additional suffering [17]. Patients being seen and understood as the human beings they truly are means experiencing This study shows that the environment is important and creates the solidarity and meaning that they long for [32]. The encounter conditions for a caring encounter [11,33]. The environment and the between the suffering human being and the nurse represents the room should offer the patient peace and quiet. When there is time and room where the patient can experience comfort and feel joy [19]. space for the encounter a communion may develop and the interplay Caring encounters requires patient centering, seeing and hearing the is successful works. Through the encounter and the conversation, the patient, that the patient is the main focus. It is important that patients nurse can together with the patient work towards fulfilling the goal. feel that the nurse has time and wants to listen to them, giving space Nurses can then demonstrate that they want what is best for the patient. for all their experiences and feelings because stress in the encounter This is when nurses encounter patients as fellow beings, they do not prevents patients from opening up. Nurses should take their time to appear from above and dominate patients through abuse of power but encounter, observe and give patients time to relate their problems, take encounter the human being with openness and on the same level the them seriously and ask questions. According to reports [14], patients patients find themselves. The patient’s dignity may thereby prevail. are aware of if nurses are authoritarian and of often being treated in The present study has shown that the creation of a caring a disparaging way. Especially those patients who initially have been communion is dependent upon the nurse’s personality and isolated or force-fed medication feel that they have not been able to trust professionalism [11]. Everything originates in how the patient has been nurses and therefore did not want to enter the encounter. The patients treated by the nurse in a true, calm and professional way, so that trust also stated that the nurses were not active in creating encounters and has emerged. Nurses should encounter the human being as a whole were unavailable. The present study has also shown that nurses through and show that they wish the other well. This form of caring love that a caring encounter can safeguard patients’ integrity and dignity so that exists in a caring relation can be explained as a sense of connection and they are not disparaged, degraded or ridiculed but feel they are being the nurse’s will to be there for and help the patient [26]. This is love as heard. This may mean that nurses have carefully explained to patients the foundation for the caring communion in the encounter because it so that they understand why the nurses choose a particular kind of care. shows the nurse’s willingness to care [25]. Research shows that if nurses

Nurs Palliat Care, 2017 doi: 10.15761/NPC.1000147 Volume 2(2): 5-7 Hemberg J (2017) The caring encounter between patient and nurse within a mental health and psychiatric care context – as described by nurses working in an emergency polyclinic

are too distant patients may not open up [8]. Gjengedal et al. [18] also new through the encounter. This enables them both to experience the indicate that nurses are required to give of themselves in the encounter encounter to be good and strengthening. These results are similar to and show their personality. By doing this, patients may experience that those of Nilsson et al. [6] who indicate that both nurse and patient can they have received a unique invitation to the encounter. Patients feel have positive experiences through a meaningful encounter. Research recognized and accepted in their own world of experience. Nordby et also shows that the encounter not only makes patients aware of their al. [7] raise the issue that a true caring encounter carries the possibility suffering but also enables reconciliation [9,19]. This study thus suggests of communion. that vulnerability is understood as the guiding star in the caring encounter between the patient and the nurse within a mental health According to Innes et al. [34], nurses who have only vague care context. knowledge about mental ill-being risk having old-fashioned thoughts and views on the encounter with patients. Piippo and Aaltonen [35], Every day is different in an emergency polyclinic, the speed is high too, emphasize that patients can feel that nurses have prejudices and and caring contacts brief. Nurses must be able to handle feelings of negative attitudes against them or their illness. These prejudices may chaos and uncertainty, and be able to make swift decisions, for instance, prevent the patients to enter the encounter because they feel they lack regarding which patient is first in need of care. Regarding psychiatric faith in the nurse. Other research [14] describes how patients often feel patients this may be difficult to see because mental ill-health is abstract abandoned with their experiences and that their feelings are sidelined and, for instance, anxiety does not always show on the outside. How in favour of other matters, which lead to experiences of loneliness is it possible to evaluate whose suffering is most difficult? This is a and not being invited to the encounter in which they could have great responsibility for nurses and many times ethical dilemmas participated and experienced communion. The encounter is vital for occur. In turn, this may sometimes lead to psychological exhaustion. patients because they can find meaning in life through it [31]. Through To constantly go from encounter to encounter as a nurse within a limit-situations, where patients are forced to come into contact mental health care context can be stressful. Feelings of inadequacy may with their suffering, reconciliation can take place. The human being emerge in the nurse as a result of lack of resources and the fact that needs another human being to cope with unbearable suffering in the in an emergency polyclinic it is not always possible to offer patients darkness of the understanding of life in a limit-situation to a bearable what they want. Experience of working in psychiatric care help nurses suffering [31]. Patients with mental ill-health often carry feelings of cope with feelings of inadequacy. A supportive work community and shame and inadequacy because of their illness [13,15]. When patients supportive nurse leaders are important for coping within a mental feel that there is no space to talk about their experiences or feelings, health and psychiatric care context, as is continuous supervision. they withdraw, which can lead to a sense of profound loneliness. Being Sharing experiences from encounters within the emergency polyclinic encountered in love and care and thereby through the encounter being with colleagues is a form of support. Maintaining professionalism able to experience communion is found to be healing. and one’s own health is fundamental. The work is performed through Do nurses today have the courage, willingness and preparedness encounters with patients where one’s own self is the tool. Difficult to encounter the patient? Research reveals that deficiencies in the encounters with patients may preferably involve two or three nurses encounter may be due to that trust is absent [15] or that patients feel and a doctor. By viewing each encounter with the patients as a unique that the nurse is not present, or does not recognize the vulnerability challenge and to strive for its success may be a way of coping in this of the patient. The most tragic scenario is perhaps when nurses caring context. For nurses, it is rewarding to feel that the patient was do not take the patient’s vulnerability seriously or use it so that the left with a good feeling, that is, caring was successful. Being passionate patient feels ridiculed or minimized. Studies have also shown that about their work may contribute to nurses finding a meaning in it the conditions for being able to enter into a caring encounter with which in turn can give them strength. It is possible to improve the patients where trust is key is that nurses are anchored in themselves quality of encounters in health care and to better cope as a nurse if the and give of themselves [9] and also have sufficient knowledge and work team discusses encounters with patients by bringing out different confidence in themselves [34] as well as affirm their own vulnerability cases among the staff and talk about what could have been done in a [18]. Affirming one’s own vulnerability as a nurse can be compared to more optimal way. being present in the encounter with the patient, having the courage to be oneself, which simultaneously means being able to be close to Strengths and limitations oneself [9] through having affirmed and reconciled with oneself. When One limitation to this study might be the limited number of nurses feel their own vulnerability they can recognize and identify the participants (only five). However, the strength of this study lies in patient’s vulnerability. This ability to see and encounter the other’s that the participants were willing to share their views in face-to-face vulnerability is missing if nurses have not first recognized their own. interviews regarding interacting with patients with mental ill-health Nurses can, once they have become aware of their own vulnerability, and establishing caring encounters with these. The interviews gave rich recognize something familiar in the other’s vulnerability in suffering data and each interview lasted up to 60 minutes. which make nurses show their own vulnerability, and open up and thereby being able to truly invite and encounter patients on the level at Conclusions which the patients find themselves. When nurses have acknowledged This study uncovers love and communion as the bases for the caring their own vulnerability they show true willingness and interest to enter encounter between the patient and the nurse within a mental health and into the encounter and receive, learn to know and help the patient. If psychiatric care context. The caring encounter may represent a source nurses dare to show their own vulnerability, patients dare to confront of strength and meaning for the patient. This study also indicates that their own vulnerability and share it with the nurses without shame. vulnerability as a phenomenon plays a fundamental role in the caring In a true caring encounter the nurse’s and the patient’s vulnerabilities encounter between the patient and the nurse in a mental health and meet, and from two fragile threads a stronger thread has been created psychiatric context. Future research should focus on how to further both in the nurse and in the patient. Both have thus received something explore this area regarding vulnerability within a mental health and

Nurs Palliat Care, 2017 doi: 10.15761/NPC.1000147 Volume 2(2): 6-7 Hemberg J (2017) The caring encounter between patient and nurse within a mental health and psychiatric care context – as described by nurses working in an emergency polyclinic

psychiatric care context, but also in relation to different care contexts. 16. Johansson IM, Skärsäter I, Danielson E (2007) Encounters in a locked psychiatric ward environment. J Psychiatr Ment Health Nurs 14: 366-372. [Crossref]

Acknowledgements 17. McAllister M, Matarasso B, Dixon B, Sheppard C (2004) Conversation starters: re- examining and reconstructing first encounters within the therapeutic relationship. J The authors would like to thank PhD Marinella Rodi-Risberg Psychiatr Ment Health Nurs 11: 575-582. [Crossref] for language editing some parts and translating other parts of the 18. Gjengedal E, Ekra EM, Hol H, Kjelsvik M, Lykkeslet E, et al. (2013) Vulnerability in manuscript. health care--reflections on encounters in every day practice. Nurs Philos 14: 127-138. [Crossref] Author contribution 19. Rydenlund K (2012) The imperative of caring in the extreme living-spaces. Jessica Hemberg was responsible for writing the article at all stages Hermeneutical caring conversations in forensic psyciatric care. (In Swedish: of the development of it as well as for the data analysis. Sofie Lipponen Vårdandets imperative i det yttersta livsrummet. Hermeneutiska vårdande samtal inom den rättspsykiatriska vården.) Doctoral thesis. Åbo Akademi University Press, Turku. conducted the data collection. 20. Eriksson K, Bondas-Salonen T, Herberts S, Lindholm L, Matilainen D (1995) The Funding Multidimensional Health – Reality and Visions. (In Swedish: Den mångdimensionella hälsan–verklighet och visioner) Sjukvårdsdistriktet SKN and Åbo Akademi University. This research received no specific grant from any funding agency in Department of Caring Science, Vasa. the public, commercial, or not-for-profit sectors. 21. Lindström UÅ, Nyström LL, Zetterlund JE (2014) Katie Eriksson. Theory of caritative caring. In: Alligood, M.R. ed. Nursing Theorists and Their work. 8th ed. Elsevier Conflict of interest Mosby, St. Louis, Missouri, USA pp: 171-201. The Authors declare that there is no conflict of interest. 22. Eriksson K (2007) Becoming Through Suffering-The Path to Health and Holiness. International J for Human Caring 11: 8-16.

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